REVIEWERS RECOGNITION PROGRAM

At Biomedicine & Prevention, we recognise that reviewers invest a great amount of their time and knowledge, in the peer-review process. For this reason we think is important to thank them. To show our appreciation, we’ve created a certificate of recognition to serve as a formal acknowledgement of reviewer’s role in the peer review-process of the journal. Reviewers can request the certificate to Biomedicine & Prevention office, which can be included in their CV.

Amer Hosin11 London University and Birmingham Medical School (UK), Emergency and Public Safety Directorate, Abu Dhabi Police GHQ, (UAE)

UNHCR (2016)1 report also suggested there are over six million (6.3 million) internally displaced Syrian refugees who suffered multiple traumas, losses, displacements, hunger and who are in places are besieged.

Meanwhile since 2014, there are 3.2 million internally displaced Iraqi refugees and there are estimated over 11 million others who are currently in need of humanitarian assistance. Though the Syrian population who remains in the country (estimated 13.5 million); and is now facing a very complex humanities crisis that includes shortage of food, shortage of medical supply and indeed requires assistance to survival harsh winter demands and conditions. In Syria and since the beginning of the war in 2011 nearly 480 000 people have been killed and major cities with its main infrastructure have also been destroyed, hence million of its citizens were forced to flee their home and later to become internally displaced or refugees in the neighbouring countries. It became clear that those Syrian who attempt the dangerous journey across the Mediterranean risk their lives and indeed not all of them succeed and make it to Europe. Those few who make it will be still facing the challenges of new, dissimilar and unknown environment including the Xenophobia and anti-refugee sentiments. Overall, the main features of many of the refugee camps where those displaced will be moving to are lacking clean water and described as overcrowded and suffer shortage of medical services – a feature which can contribute to spread of life-threatening diseases. It should be started here that half of the displaced refugees are women and under age of 18; most of them without any formal education; basically traumatized.

Focusing on funding policies, the UN fund has been significantly decreased in recent years, and the USA, the UK and few other European donor countries are not only reluctant to take refugees now, but significantly slashing their contribution to assist the UN missions and work which meant to stabilize communities, built shelters and provide food throughout war regions; with aims to help these millions of traumatized displaced population to develop resiliency and hence cope with their losses. The new US administration is curtailing legal immigration and refugee from 110 000 to 45 000 annually and hence set a record-low on refugees in 2017. It is worth noting that some of these refugees such as the Yazidi minority of Iraq have witnessed and on the hand of the so called Islamic State of Iraq and the Levant (Isis or Daesh) rape experiences, slavery of hundreds of Yazidi’s women, death and extreme brutality including killing and burying women and children alive.

Similarly, the recent sectarian situation in Myanmar is not different, the extreme violence and ethnic cleansing committed by the Burmese Army and few extremist Buddhists resulted according to Reuters (2018)2 in 690 000 Rohingya families to flee their home and indeed witnessed their loved ones have been murdered. The majority of these fleeing refugees to Bangladesh were women, children and newly born babies who arrived hungry, suffering exhaustion, physically tired and unwell (see also the recently published Independent report, 2018). The Rohingya community has accused the Burmes army of arson, rapes and killings of the 10 captive Muslim on September 2nd in the coastal village of Inn Din. As a result, the UN expected now to manage large exodus such as this. Indeed, this is what happen when extreme hatred, criminal and pathological genocidal behaviour surfaced when the west represented by the international community, largely USA and Europe, fail or delay taking action, hence confront criminals with the necessary and due punishment. Given the civil war in Syria and the instability in Iraq, it seems the direction of forced migration for many people will continue in both countries.

As noted, this chapter is designed to examine international policies and the adjustment processes among both traumatised and exiled refugees who live in a host culture. It is also hoped that the work will be extended to answer few important questions on how children react to the refugee experience, how they adjust to and cope in the host culture, and what their mental health problems are? The answers provided to these questions are important to a number of professionals and individuals, e.g. policy makers, researchers and many practitioners such as psychiatrists, psychologists, social workers, mental health nurses etc. There is very little attention that has been paid to the links between policies and adjustment of traumatised refugees in the host culture.

According to Hosin3,4 every year few thousands of children arrive in the UK without a parent or guardian to look after them. Some of these children arrived completely alone while others were with relatives or non-governmental organizations. Their parents could be dead, ill, imprisoned or simply did not have the money to flee as well. The reasons for leaving a country can vary widely, and can include mainly ethnic cleansing, community violence and armed conflicts that target children to forced military service. Rape is a common element in the pattern of prosecution, terror, and ethnic cleansing that uproot refugee families from their homes and communities. The UNHCR in their world wide web page reported that from Somalia to Bosnia refugee families frequently cite rape or the fear of rape as a key factor in their decision to leave. Hosin3 further added that it has been also estimated that no less than 20-30% of refugees up to 1990 have been tortured.

Upon arriving to refugee camps and host nations, Hosin3 reported that the most common manifested symptoms among these refugees were sleep disturbances, nightmares, headaches, impaired memory, poor concentration, fatigue, fear/anxiety and social withdrawal. It should be emphasized here that due to their near-death experiences and exposure to violence either before or during the flight, many adults are unable to function adequately as parents, spouses, employees, or citizens and they are likely to experience a series of strained relationships as a result. In addition, their mental health problem is significantly higher when compared with the general non-refugee population.

It is possible to suggest that children’s adjustment in the host nation is often influenced by their parents’ history of unpleasant interactions with the environment. Indeed, in some cases, a parent’s depression can contribute directly to the child’s difficulties and poor adjustment among children.5-7 It should also be remembered that while refugee experiences can generate a number of mental health problems, some refugees are reluctant to seek help, and their tendency to somatize emotional problems is particularly common because they come from societies that stigmatize mental illnesses. Various writers, however, seem to place emphasis on different variables to help refugees to make the transition and adjust to the host and unfamiliar culture. Ward et al8 for example, claimed that the successful adjustment in the unfamiliar culture is greatly dependent on not only individual but on other situational factors and the reasons for the exposure to the host culture (i.e. reasons for the contact), the length of the stay as well as culture norms and policies. Furthermore, Ward and Kennedy, 1994; Berry et al, 19928,9 maintained that both assimilation polices and integration policies are facilitative strategies for adjusting into the new culture as compared to separation policies.

Focusing further on the traumatised individuals of war regions, parental adjustment and children’s reactions, Smith et al (2001)9 cited several studies and reported that children’s reactions to direct exposure and living through war conditions may contribute to producing negative outcomes, including high levels of PTSD symptoms among children who have survived armed conflict This study further added that traumatic stressors in war are commonly multiple, diverse, chronic and repeated. Other early researchers in this area such as Bryce et al (1989)10 and Dawes et al (1989)11 have focused on parental adjustment and children’s reactions to traumatic events. In fact, all these pioneer work and early studies (including Smith et al’s study) which were conducted in former conflict regions such as Lebanon, South Africa and Bosnia have found that parental mental health, particularly that of mothers in times of conflict, was a significant predictor of children’s adjustment.

It is worth noting here that the extent of vulnerability depends on the impact of violence and migration on the child’s family and community. This may include witnessing the death and injury of a parent or sibling and perhaps persistent exposure to death, destruction and ultimately separation from parents. Other risk factors may include sudden (unanticipated) death of parents or siblings, radical change in family circumstances and roles, poor access to family support and an unstable, inconsistent environment. It would be fair to suggest here that rapidly changing environments with little stability as well as parental psychopathology and lack of security or protection have implications on the physical health and mental well-being of the refugee population, for assessment and treatment of refugees of multiple trauma, see Hosin (2007).3

Overall, refugee assessments demand special sensitivity to anxiety, fear, shyness, reassurance, clarity and understanding. Refugees are individuals with a well-founded fear arising from one of a number of causes including witnessing malicious violence and losses to being subject to interrogation, imprisonment and oppression. Hence, research instruments used with the refugee population should be unintrusive, unprovocative and sensitive to the participant’s culture and values. Jumaian, Hosin and Rahmatallh (1997)12 touched on this issue by suggesting that the treatment approach for survivors of traumatic events often begins with debriefing. Other studies13-16 suggested that there is a wide range of effective strategies including group therapy, behaviour and cognitive approaches, desensitisation, flooding techniques as well as relaxation training used for tension, anxiety and intrusive thoughts. Most of these techniques can help sufferers to enhance their coping skills. In any event, Yule and Canterbury (1994)17 suggested that treatment approaches need flexibility and both clinicians and therapists should be prepared to draw upon a wide range of available techniques. Priority should be given to those at risk. Furthermore, whatever approach is used, establishing a supportive, trusted relationship and being in a safe environment are essential elements in therapy.

Deterrent, Injustice National and International Policies on Displaced Population and Refugees of Multiple Traumas

The focus of this section shall emphasize on certain deterrent and injustice national and international policies on refugees of multiple traumas; and hence try to orient the readers to few of these national and International legislation and policies that may exacerbate the trauma experience among such vulnerable groups.

As stated, refugees arrive to a host culture with a wide range of experiences, including witnessing massacres and threats of massacres, detention, torture, sexual assault, rape, escaping torture, genocide as well as destruction of homes and property and forcible eviction, etc. Unfortunately, and despite the guidelines of the 1951 Geneva Convention which tends to protect and care for refugees, most Western countries now are seeking to implement new injustice deterrent policies characterized (in some countries) by indefinite detention of all refugees including children, women and young adult men who arrive at their shores and ports of entry. This is very much the case in Australia and to some extent the Netherlands, Germany and in Britain. Britain detains illegal immigrants at detention camps (e.g. at the fast track Oakington reception centre near Cambridge) particularly those awaiting forced deportation.

With regard to target and removal policies, some European countries including France recently adopted of removal of failed asylum seekers and unsuccessful applications as quickly as possible. France, for example, recently pledged of deportation and setting target returning home thousands of unsuccessful applicants including some of those whose countries are still unstable or suffering raging war conditions and political upheaval. Also exceptional leaves to remain are hardly considered for many of such applicants.

Other internationall refugee policies that are discussed here are of Canada, Australia and the USA. For example, the number of refugees who try to enter Canada or Australia is far smaller than those who applied to come to Germany, France or Britain. Since it was first introduced in 1994 by Australia’s Labour Government, Australia’s refugee policy not only isolates refugees from the real world but offers refugees indefinite, harshest detention and injustice policy. That is detain indefinitely all men, women and children until the authorities decide whether or not they deserve refugee status. Overall, this large two countries (Canada and Australia) are not only offering very few permanent refugee places each year taken from a UNHCR or United Nation High Commission for Refugees but their processes are slow, identify or emphasis only possible young labor force who would be beneficial to market demands in these two countries. This kind of hand picked processes ‘adopted policies’ are resulting in disadvantage all of hard hit traumatized and elderly refugee applicants. Indeed, the outcomes of such inhuman, repellent and immoral policies which practiced by certain countries resulted thus far in fewer places for elderly refugees. Due to such hand-picked policy practices which often repel elderly and sick refugees, today elderly refugees represent only 4% of the total worldwide number who successfully claimed refugee statue in host nations. Focusing again on detention policy, a former staff who works in some of most oppressive, remote detention camps in Australia (namely in Woomera remote detention camp) described the psychological well-being of detainees as very poor. Many suffered high level anxiety and were on antidepressant drugs. It must be mentioned here that a total of 139 countries have signed the 1951 Geneva Refugee Convention; however, international protection of refugees comprises more than physical safety. That is, refugees should at least receive the same rights and basic help as any other foreigner who is legal resident, including certain fundamental entitlements of every individual. That is, refugees should have basic civil rights including freedom of movement, thought, and freedom from repressive psychological torture and degrading treatment. Thus as a general rule, detention of asylum-seekers is not acceptable by international law. It is particularly undesirable, the UNCHR claimed, when those detained include are the very vulnerable, children, single women and people with special medical and psychological needs.

Many countries are aware that the 1951 Geneva Convention specifically bars countries from punishing people who have arrived directly from a country of persecution provided that they present themselves speedily to the authorities and show good cause for their illegal entry. With regard to detention and repatriation policies of failed asylum, France, Germany, Denmark, the Netherlands, Austria, Switzerland and the United Kingdom have already sent traumatize displaced population and traumatize asylum-seekers home, even some were on hunger strike and awaiting for appeal outcomes. Further the UK government regulations on asylum indicate that asylum-seekers can only get residency in Britain if they meet the 1951 UN Convention's definition of a refugee. This means they must have a “well-founded fear of persecution” on the grounds of race, religion, nationality, membership of a particular social group or political opinion.

Meanwhile in the USA, the new administration and through presidential executive order has pledged to build a wall along the Mexican border and plan mass deportation of undocumented immigrants; including the so called ‘Dreamers’ who were brought to the US as children. This whole plan estimated to effect 11 million undocumented immigrants in the USA and also envisage to discourage immigration and asylum seeking in this nation which was built by skilled immigrants.

Overall, refugee community organizations are invaluable in supporting refugees. They can provide information and orientation and reduce the isolation experienced by so many refugees. A study of Iraqi asylum seekers have found depression was more closely linked with poor social support than with a history of torture. It is important for refugees to develop ongoing links and friendships with people in the host community, hence not to be put in detention camps. Further details on the health and well-being of asylum seekers and refugees of multiple traumas can be found in Hosin;3,4 Burnett and Peel.18-20